252. Improved overall survival with additional surgical resection after polypectomy for T1 colorectal cancer

S102 249. Bladder sparing technique in partial pelvic exenterations in locally advanced rectal cancer with recto-vaginal and recto-vesical fistulas: The possibility of primary anastomoses and risk factors of their insolvency I. Kryvorotko1 1 Institute of General and Urgent Surgery National Academy of Sciences of Ukraine, Urgent Surgery, Kharkiv, Ukraine Background: Pelvic exenteration remains a gold standard for patients with locally advanced rectal cancer complicated with recto-vaginal or recto-vesical fistulas. Bladder preservation and primary colo-anal anastomoses with complete tumor resection is often possible procedure. The reasons of adverse outcomes are the insolvency of urinary or coloanal anastomoses. We set out to determine if bladder sparing operations or primary anastomotic technique can decrease the postoperative morbidity and 5-year survival rate and to identify the main risk factors of anastomotic leakage. Material and methods: Between 2003 and 2013, 52 partial pelvic exenterations was performed for the primary (36) and recurrent (26) rectal cancer complicated by the recto-vaginal (31) and recto-vesical (21) fistulas. An evaluation of prognostic factors for anastomotic leakage, mortality rate and overall survival was made. Results: Combined operations were performed at 52 patients accounting for 7.4% of the total number (703) operations for rectal cancer. A total of 27 patients were treated by posterior exenteration (anterior rectal resection and hysterectomy and vaginectomy en bloc), 19 patients were treated by combined posterior exenteration (rectal resection with hysterectomy and resection of bladder/left ureter) and 6 patients were treated by the classic total pelvic exenteration (abdominoperineal rectum resection with prostate and vesiculectomy and resection of prostatic uretra and lower third of both ureters). Urinary diversion was achieved by construction of a Boary-flap (8), ileal conduit (6), ileal bladder augmentation (3), transverse colon conduit (3) and double-barreled wet colostomy (2). Primary colo-anal anastomoses were performed in 35 from 46 sphincter spared patients (76%). The histological study identified the presence of the direct tumor invasion in the adjacent organs in the 48 patients (92,4%), inflammatory penetration was identified in 4 patients (7,6%). Microscopically complete resections (R0) were achieved in 94%. Total of 74 anastomoses in 46 patients were performed (39 ureteral and 35 intestinal). Signs of leakage were found in 9 patients (leakage rate made up 17.3%). In the group of anastomotic leakage in comparison to non leaked anastomoses (9/39) were found an oppression of a cellular link of immunity, augmentation of cytotoxicity of blood serum, 10-fold increase urinary excretion of amino acid oxyproline as a markers of the disintegration of collagen type 1.The average follow up from surgery was 42 months (range 8-96). The 5-year overall survival rate made up 48%. Anastomotic leakage, and an incomplete resection negatively influenced the 5-year overall survival. Conclusions: New methods of combined operations compared with total pelvic exenterations allowed to improve early and late outcomes with satisfactory medical and social adaptation of patients after resections of the adjacent organs. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.242

251. Is laparoscopy-assisted colectomy superior to open colectomy? Comparison of the long term postoperative course and prognosis Y. Tsuchiya1, S. Kawai1, K. Tazawa1, H. Yamagishi1, H. Arai2, T. Manabe3, S. Sekine3, T. Okumura3, T. Nagata3, K. Tsukada3 1 Itoigawa General Hospital, Department of Surgery, Itoigawa, Japan 2 Keinan General Hospital, Department of Surgery, Myoko, Japan 3 University of Toyama, Department of Surgery and Science, Toyama, Japan

ABSTRACTS Background: We introduced laparoscopy-assisted colectomy (LAC) and contributed to improve the postoperative course. In this study, we compared the long term postoperative course and prognosis between LAC and open colectomy (OC) in sigmoid and rectosigmoid cancer. Material and methods: Analysis subjects were 114 cases that underwent sigmoidectomy or anterior resection of the rectum with two or threefield lymphadenectomy from January 2003 until December 2012. They were divided into two groups: patients performed OC (the Ogroup, n¼64): patients performed LAC (the L group, n¼50). Our retrospective analysis was focused on the long term postoperative course and prognosis. Results: LAC was superior to OC in disease free survival (DFS) (P¼0.0330 by Wilcoxon test, P¼0.0338 by log-rank test) and overall survival (OS) (P¼0.0413 by Wilcoxon test, P¼0.0727 by log-rank test). Under stage II, cancer recurrence occurred around one year after the surgery in the O group, but there was no cancer recurrence in the L group. Moreover over stage III, the L group was superior to the O group in OS (P¼0.0392 by Wilcoxon test, P¼0.0856 by log-rank test). The ratio of occurrence of small bowel obstruction and incisional hernia and use of laxative or antiflatulent one year after the surgery in the L group and the O group were 4.0% vs. 17.4% (P¼0.018), 2.0% vs. 6.3%, 30.0% vs. 75.8%(P<0.001) respectively. Conclusions: Compared with OC, LAC reduces the frequency of small bowel obstruction and the use oflaxative or antiflatulent one year after the surgery. Furthermore, LAC delay the recurrence of cancer compared with OC in the same surgical procedure. These results strongly suggest that LAC is superior to OC in the long term postoperative course and prognosis. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.243

252. Improved overall survival with additional surgical resection after polypectomy for T1 colorectal cancer F.N. Van Erning1, T.D.G. Belderbos2, P.D. Siersema2, I.H.J.T. De Hingh3, V.E.P.P. Lemmens1 1 Comprehensive Cancer Centre The Netherlands, Research, Eindhoven, Netherlands 2 University Medical Centre Utrecht, Gastroenterology and Hepatology, Utrecht, Netherlands 3 Catharina Hospital, Surgery, Eindhoven, Netherlands Background: With the introduction of screening programs for colorectal cancer, early stage cancers are expected to be more frequently diagnosed. Controversy exists on the management of patients with pathologically confirmed T1 colorectal cancer (pT1 CRC) after initial polypectomy. We aimed to identify factors associated with additional surgical resection in a large cohort of patients and to compare overall survival between patients undergoing additional surgery versus polypectomy only. Material & methods: All pT1 CRC patients who underwent polypectomy and were diagnosed in the area of the Eindhoven Cancer Registry between 1995-2011 were included. Multivariable logistic regression was used to assess patient and tumour characteristics associated with additional surgical resection. Crude 5-year overall survival was based on Kaplan-Meier curves and Cox regression analysis was used to discriminate the independent effect of additional surgical resection on the risk of death after adjusting for relevant patient and tumour characteristics. Results: In total, 827 patients with pT1 CRC who underwent polypectomy were included, of whom 260 (31%) underwent additional surgical resection. As compared to patients undergoing polypectomy only, patients in whom additional surgical resection was performed were younger (mean age 65.1 versus 68.5, p<0.0001), more often had no comorbidity (34% versus 25%, p¼0.008) and more often had a tumour located in the colon (71% versus 63%, p¼0.017). In multivariable analysis, elderly and patients with a tumour located in the rectosigmoid or rectum were less likely to undergo additional surgical resection (OR 80 years versus 60-69 years 0.22:

ABSTRACTS 95% CI 0.11-0.43; OR rectosigmoid/rectum versus colon 0.65: 95% CI 0.46-0.90). Crude 5-year overall survival was higher in the group of patients who underwent additional surgical resection as compared to patients who underwent polypectomy only (82% versus 75%, p¼0.002). Also after adjusting for patient and tumour characteristics, patients who underwent additional surgical resection had a decreased risk of death as compared to patients who underwent polypectomy only (HR 0.68: 95% CI 0.500.93). Conclusions: Elderly with a tumour located in the rectosigmoid or rectum were less likely to undergo additional surgical resection. Given that additional surgical resection was independently associated with improved overall survival, this might imply that all pT1 CRC patients should receive additional surgical resection after initial polypectomy. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.244

253. Hypofractionated chemoradiotherapy with local hyperthermia and metronidazole for fixed or tethered T4 rectal cancer S. Gordeyev1, Y.U.A. Barsukov1, S.I. Tkachev2 1 Blokhin Cancer Research Center, Proctology, Moscow, Russian Federation 2 Blokhin Cancer Research Center, Radiational Oncology, Moscow, Russian Federation Background: Preclinical studies support additive effect of hypofractionated radiotherapy, local hyperthermia and metronidazole. The aim of this study was to prospectively evaluate the safety and efficacy of neoadjuvant chemoradiotherapy with local hyperthermia and metronidazole for fixed T4 rectal cancer. Methods: Patients received radiation therapy 40 Gy in 10 fractions thrice a week. Chemotherapy consisted of Capecitabine 650 mg/m2 bid per os on days 1-22, oxaliplatin 50 mg/m2 intravenously on days 3, 10, 17. Local hyperthermia 41-45 C, 60 minutes was performed on days 8, 10, 15, 17. Metronidazole 10 g/m2 per rectum was used on days 8, 15. Surgery was carried out within 6-8 weeks after neoadjuvant treatment. Primary endpoint was R0 rate. Secondary endpoints included toxicity, tumor regression, 2-year OS and DFS, local recurrence rate. Results: Between Sept.2007 and Jan.2011, a total of 116 consecutive patients were enrolled (median age 57 years; 72 male, 44 female; median tumor diameter 8 cm). R0 resection rate was 90,5%. 5(4,3%) patients remained inoperable, 6(5,2%) had R1 resection. 26(22,4%) patients experienced G3-G5 toxicity (23 Grade 3/4 and 3 Grade 5). There was no postoperative mortality. 48(41,4%) patients had near-complete and 10(8,6%) patients - complete response. Median follow-up was 21.9 months. 2-year OS was 82.6%, 2-year DFS was 70.9%. 30(25.9%) patients had disease progression. 13(11.2%) patients had local recurrences, 22(19%) patients developed metastatic disease. Conclusion: High R0 resection rate in fixed or tethered rectal cancer in our study warrants further investigation of the proposed treatment scheme in a randomized setting. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.245

254. A novel chemoradiotherapy regimen for squamous-cell anal cancer A. Malikhov1, U.A. Barsukov1, A.V. Nikolaev1, D.F. Kim1, U.M. Timofeev1 1 Blokhin’s Russian Cancer Research Center, Coloproctology, Moscow, Russian Federation The aim of this trial was to investigate safety and efficacy of anal cancer chemoradiotherapy with cisplatin, bleomycin and local hyperthermia.

S103 Methods: This retrospective trial included 157 consecutive patients, who underwent chemoradiotherapy for squamous-cell anal cancer during 1998-2011. All patients received 36-48 Gy radiotherapy in 2 Gy fractions followed by a boost (after 2 week gap) till a total dose of 64-70 Gy was achieved. Chemotherapy included intravenous cisplatin 20 mg/m2 days 1,3 weeks 1-4, intramuscular bleomycin days 2,4, weeks 1-4. 5 sessions of local 41-45 C hyperthermia were carried out during the radiotherapy course. Results: Complete clinical response was achieved in 126 (80,3%) patients, 31 (19,7%) patients underwent abdominoperineal resection. Median followup was 30 months. 24 (16,9%) patients died from disease progression, including 10 (7,0%) patients with local recurrence. 5-year survival rate was 73,7 %. Conclusion: Anal cancer chemoradiotherapy with cisplatin, bleomycin and local hyperthermia seems a feasible alternative to standard treatment, the efficacy of this regimen needs to be validated in prospective trials. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.246

255. Rectal cancer treatment and complications in IBD patients S.J. Van Rooijen1, S.L. Bosch2, H.J.W. Braam1, G.M.J. B€okkerink1, I.D. Nagtegaal2, J.H.W. De Wilt1 1 Radboud University Medical Center, Surgery, Nijmegen, Netherlands 2 Radboud University Medical Center, Pathology, Nijmegen, Netherlands Background: IBD patients have an increased risk of developing colorectal cancer(CRC). For sporadic rectal cancer (RC), neoadjuvant therapy followed by total mesorectal excision (TME), is standard of care. Data on the effects of this treatment for IBD related RC are rare, since IBD patients are usually excluded from neo-adjuvant trials. Materials and methods: All IBD patients of the Netherlands with RC between 1990 and 2010 were selected using a nationwide search in the Dutch Pathology Database (PALGA). Clinical data were collected from detailed medical record review in each hospital. All histopathological slides were reviewed to confirm both diagnoses. Surgical complications were scored according to the Clavien-Dindo scale (Grade 1 to 5). Results from IBD patients with RC were compared with data from the Dutch surgical colorectal audit containing all CRC patients treated in the Netherlands. Results: 173 patients from 40 hospitals were identified (89 Ulcerative Colitis (UC), 70 Crohn’s Disease (CD), 14 indeterminate colitis). 112 (64.7%) were males and 61 (35.3%) females with mean age of RC diagnosis of 60.7 years (28.2e92.4). The mean duration of IBD before development of RC was 17.4 years (0e50.9). Neoadjuvant therapy was used in 63 (36.4%) patients, 29 (17.9%) received short course radiotherapy (RT), 13(8.3%) long course RT, 21 (13.1%) chemoradiation therapy (CRT). 154 (89.1%) patients underwent resection of the tumor. Diagnosis of RC was known preoperatively in 145 (83.8%) patients (CD 72.7% and UC 90.9%; p¼0.022). Stage distribution was: 1 patient stage 0 (0.9%), 27 stage I (23.9%), 41 stage II (36.3%), 30 stage III (26.5%), and 14 stage IV (12.4%). 42% of the patients developed one or several complications after rectal surgery. Complication grade 2 was reported most, 26 (27,4%) times, as a presacral or intra-abdominal abscess (15.8%), perineal or abdominal wound (26.3%) or urologic (20%) cause. 48 grade 3+ complications were reported in 41 (24.4%) patients. No more complications were seen with neoadjuvant therapy usage nor immunosuppressive. Local recurrence was seen in 14 (8,1%) patients. Conclusions: Rectal cancer is often not recognized in patients with IBD who undergo surgery. This leads to a high number of R1 resections and an increased local recurrence rate, especially in patients with CD. The complication rate after TME surgery in IBD patients seems comparable with sporadic RC patients. No conflict of interest. http://dx.doi.org/10.1016/j.ejso.2014.08.247